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Article in English | WPRIM | ID: wpr-927654


Objective@#To explore associations between lipoprotein-associated phospholipase A2 (Lp-PLA2) and the risk of cardiovascular events in a Chinese population, with a long-term follow-up.@*Methods@#A random sample of 2,031 participants (73.6% males, mean age = 60.4 years) was derived from the Asymptomatic Polyvascular Abnormalities Community study (APAC) from 2010 to 2011. Serum Lp-PLA2 levels were determined by enzyme-linked immunosorbent assay (ELISA). The composite endpoint was a combination of first-ever stroke, myocardial infarction (MI) or all-cause death. Lp-PLA2 associations with outcomes were assessed using Cox models.@*Results@#The median Lp-PLA2 level was 141.0 ng/mL. Over a median follow-up of 9.1 years, we identified 389 events (19.2%), including 137 stroke incidents, 43 MIs, and 244 all-cause deaths. Using multivariate Cox regression, when compared with the lowest Lp-PLA2 quartile, the hazard ratios with 95% confidence intervals for developing composite endpoints, stroke, major adverse cardiovascular events, and all-cause death were 1.77 (1.24-2.54), 1.92 (1.03-3.60), 1.69 (1.003-2.84), and 1.94 (1.18-3.18) in the highest quartile, respectively. Composite endpoints in 145 (28.6%) patients occurred in the highest quartile where Lp-PLA2 (159.0 ng/mL) was much lower than the American Association of Clinical Endocrinologists recommended cut-off point, 200 ng/mL.@*Conclusion@#Higher Lp-PLA2 levels were associated with an increased risk of cardiovascular event/death in a middle-aged Chinese population. The Lp-PLA2 cut-off point may be lower in the Chinese population when predicting cardiovascular events.

1-Alkyl-2-acetylglycerophosphocholine Esterase/blood , Asians , Cardiovascular Diseases/diagnosis , China/epidemiology , Female , Humans , Longitudinal Studies , Male , Middle Aged , Mortality , Myocardial Infarction/blood , Predictive Value of Tests , Risk Factors , Stroke/blood
Clinics ; 74: e1222, 2019. tab, graf
Article in English | LILACS | ID: biblio-1039547


OBJECTIVES: Ischemic stroke (IS) or transient ischemic attack (TIA) history is present in 4-17% of patients with coronary artery disease (CAD). This subgroup of patients is at high risk for both ischemic and bleeding events. The aim of this study was to determine the role of platelet aggregability, coagulation and endogenous fibrinolysis in patients with CAD and previous IS or TIA. METHODS: A prospective case-control study that included 140 stable CAD patients divided into two groups: the CASE group (those with a previous IS/TIA, n=70) and the CONTROL group (those without a previous IS/TIA, n=70). Platelet aggregability (VerifyNow Aspirin® and VerifyNow P2Y12®), coagulation (fibrinogen and thromboelastography by Reorox®) and endogenous fibrinolysis (D dimer and plasminogen activator inhibitor-1) were evaluated. RESULTS: Patients in the CASE group presented significantly higher systolic blood pressure levels (135.84±16.09 vs 123.68±16.11, p<0.01), significantly more previous CABG (25.71% vs 10%, p=0.015) and significantly higher calcium channel blocker usage (42.86% vs 24.29%, p=0.02) than those in the control group. In the adjusted models, low triglyceride values, low hemoglobin values and higher systolic blood pressure were significantly associated with previous IS/TIA (CASE group). Most importantly, platelet aggregability, coagulation and fibrinolysis tests were not independently associated with previous cerebrovascular ischemic events (CASE group). CONCLUSION: Platelet aggregability, coagulation and endogenous fibrinolysis showed similar results among CAD patients with and without previous IS/TIA. Therefore, it remains necessary to identify other targets to explain the higher bleeding risk presented by these patients.

Humans , Male , Female , Middle Aged , Aged , Blood Coagulation/physiology , Coronary Artery Disease/blood , Ischemic Attack, Transient/blood , Platelet Aggregation/physiology , Stroke/blood , Fibrinolysis/physiology , Platelet Function Tests , Blood Coagulation Tests , Coronary Artery Disease/physiopathology , Case-Control Studies , Ischemic Attack, Transient/physiopathology , Prospective Studies , Stroke/physiopathology
Rev. Assoc. Med. Bras. (1992) ; 64(5): 438-442, May 2018. tab, graf
Article in English | LILACS | ID: biblio-956475


SUMMARY OBJECTIVE The present study aims to investigate whether hyperhomocysteinemia (HHcy) affects the outcomes of the thrombolytic treatment for patients with AIS. METHODS A sample of 120 AIS patients were recruited and grouped according to their serum homocysteine (Hcy) levels. The National Institute of Health Stroke Scale (NIHSS) was obtained before treatment and 7 days after it to evaluate neurological outcomes; modified Rankin Scale (mRS) was obtained 12 weeks later to assess functional outcomes. Receiver operating characteristic curve (ROC) was used to demonstrate the relationship between serum Hcy level and the outcomes after tPA treatment. RESULTS The serum Hcy level of 120 patients was of 27.57±20.17μmol/L. The NIHSS scores of the patients in the low Hcy level group were remarkably lower compared to those in the high-level group (p<0.05), after 7 days of treatment. In addition, the mRS scores of the patients in the low Hcy level group, after 12 weeks, were remarkably lower compared to those in the high-level group (p<0.01). ROC demonstrated that the serum Hcy level is related to the clinical outcomes of thrombolytic treatment with moderate specificity (80.3%) and sensitivity (58.2%). CONCLUSION In conclusion, higher serum Hcy levels can indicate poorer clinical outcomes of thrombolytic treatment in patients with AIS.

RESUMO OBJETIVO O presente estudo tem por objetivo investigar se a hiperhomocisteinemia (HHcy) afeta os resultados do tratamento trombolítico em pacientes com AVCI agudo. METODOLOGIA Uma amostra de 120 pacientes AVCI agudo foi recrutada e agrupada de acordo com os níveis séricos de homocisteína (Hcy). Uma avaliação nos padrões do National Institute of Health Stroke Scale (NIHSS) foi obtida antes do tratamento e 7 dias após ele para avaliar desfechos neurológicos e a escala de Rankin modificada foi utilizada 12 semanas depois para avaliar os desfechos funcionais. A curva ROC (Receiver Operating Caracteristic) foi utilizada para demonstrar a relação entre os níveis séricos de Hcy e os desfechos após tratamento com t-PA. RESULTADOS Os níveis séricos de Hcy de 120 pacientes foi de 27,57±20,17μmol/L. Os escores NIHSS dos pacientes no grupo de baixo nível de Hcy foram notavelmente mais baixos em comparação àqueles do grupo de nível mais alto (p<0,05), após 7 dias de tratamento. Além disso, os escores mRS dos pacientes no grupo de baixo nível de Hcy, após 12 semanas, foram consideravelmente mais baixos em comparação com os do grupo de alto nível (p<0,01). A curva ROC demonstrou que o nível sérico de Hcy tem relação com os desfechos clínicos do tratamento trombolítico com especificidade moderada (80,3%) e sensibilidade (58,2%). CONCLUSÃO Podemos concluir então que níveis séricos mais altos de Hcy podem prever desfechos clínicos piores para o tratamento trombolítico em pacientes com AVCI agudo.

Humans , Male , Female , Aged , Thrombolytic Therapy , Hyperhomocysteinemia/blood , Stroke/drug therapy , Stroke/blood , Homocysteine/blood , Prognosis , Severity of Illness Index , Risk Factors , ROC Curve , Administration, Intravenous , Middle Aged/physiology
Rev. Assoc. Med. Bras. (1992) ; 64(5): 428-432, May 2018. tab
Article in English | LILACS | ID: biblio-956463


SUMMARY OBJECTIVE To analyze the effect of mecobalamin on the early-functional outcomes of patients with ischemic stroke and H-type hypertension. METHODS From October of 2014 to October of 2016, 224 cases of ischemic stroke and H-type hypertension were selected. The patients were randomly divided into treatment control groups, with 112 patients in each group. The control group was treated with the conventional therapy. The observation group was treated with 500 µg of mecobalamin three times a day in addition to the conventional therapy. We compared serum homocysteine (Hcy), hs-CRP levels, carotid plaques, and NIHSS scores between the two groups on the 2nd day and at 4 weeks, 8 weeks, 3 months, and 6 months. RESULTS After 4 weeks, 8 weeks, 3 months and 6 months, the difference of serum Hcy level between the two groups was statistically significant (t = 4.049, 3.896, 6.052, 6.159, respectively. All P <0.05). After the treatment, at 4 weeks, 8 weeks, 3 months and 6 months, the levels of hs-CRP in the treatment group were significantly lower than those in the control group (t = 37.249, 28.376, 26.454, 20.522, respectively. All P <0.01). After 3 months and 6 months, the carotid artery plaques were significantly reduced in the treatment group compared to those in the control group (t = 2.309 and 2.434. All P <0.05). After 3 months and 6 months, the NIHSS score was significantly higher in the treatment group compared to those in the control group (t = 2.455 and 2.193. All P <0.05). CONCLUSION Mecobalamin can reduce the level of plasma homocysteine, then lead to reductions of levels of plasma inflammatory factors and volume of carotid artery plaques, resulting in more significant functional recovery.

RESUMO OBJETIVO Analisar o efeito de mecobalamin sobre os primeiros resultados funcionais de pacientes com AVC isquêmico e hipertensão H-type. MÉTODOS De outubro de 2014 a outubro de 2016, 224 casos de AVC isquêmico e hipertensão H-type foram selecionadas. Os pacientes foram divididos aleatoriamente em grupo de tratamento e grupo controle, com 112 doentes em cada grupo. O grupo controle foi tratado com a terapia de rotina. O grupo de observação foi tratado com 500 µg de mecobalamin três vezes por dia, além da rotina de tratamento. No segundo dia, 4 semanas, 8 semanas, 3 meses e 6 meses, comparamos níveis séricos da homocisteína (Hcy) e de hs-CRP, placas da carótida e pontuações NIHSS entre os dois grupos. RESULTADOS Após 4 semanas, 8 semanas, 3 meses e 6 meses, a diferença dos níveis séricos de Hcy entre os dois grupos foi estatisticamente significativa (t= 4,049, 3,896, 6,052, 6,159, respectivamente. Todos os P<0,05). Após o tratamento de 4 semanas, 8 semanas, 3 meses e 6 meses, os níveis de hs-CRP no grupo de tratamento foram significativamente inferiores aos do grupo controle (t=37,249, 28,376, 26,454, 20,522, respectivamente. Todos os P<0,01). Depois de 3 meses e 6 meses, as placas da artéria carótida foram significativamente reduzidas no tratamento, em comparação com os do grupo controle (t=2,309 e 2,434. Todos os P<0,05). Depois de 3 meses e 6 meses, as pontuações NIHSS foram significativamente mais elevadas no tratamento em comparação com as do grupo controle (t=2,455 e 2,193. Todos os P<0,05). CONCLUSÃO Mecobalamin pode reduzir o nível de homocisteína plasmática, o que conduz à redução dos níveis de plasma inflamatórios e do volume das placas na artéria carótida, resultando em maior recuperação funcional.

Humans , Male , Female , Aged , Aged, 80 and over , Vitamin B 12/analogs & derivatives , Stroke/drug therapy , Homocysteine/blood , Hypertension/drug therapy , Hypertension/blood , Prognosis , Vitamin B 12/therapeutic use , Brain Ischemia/blood , Treatment Outcome , Stroke/blood , Middle Aged
Arq. neuropsiquiatr ; 75(12): 881-889, Dec. 2017. tab, graf
Article in English | LILACS | ID: biblio-888281


ABSTRACT Aiming to contribute to studies that use detailed clinical and genomic information of biobanks, we present the initial results of the first Latin American Stroke Biobank. Methods: Blood samples were collected from patients included in the Joinville Stroke Registry and four Brazilian cities. Demographic socio-economic data, cardiovascular risk factors, Causative Classification System for Ischemic Stroke, Trial of Org 10172 in Acute Stroke Treatment and National Institutes of Health scores, functional stroke status (modified Rankin) and brain images were recorded. Additionally, controls from both geographic regions were recruited. High-molecular-weight genomic DNA was obtained from all participants. Results: A total of 2,688 patients and 3,282 controls were included. Among the patients, 76% had ischemic stroke, 12% transient ischemic attacks, 9% hemorrhagic stroke and 3% subarachnoid hemorrhage. Patients with undetermined ischemic stroke were most common according the Trial of Org 10172 in Acute Stroke Treatment (40%) and Causative Classification System for Ischemic Stroke (47%) criteria. A quarter of the patients were under 55 years of age at the first-ever episode. Conclusions: We established the Joinville Stroke Biobank and discuss its potential for contributing to the understanding of the risk factors leading to stroke.

RESUMO Com o objetivo de contribuir para estudos que utilizam informações clínicas e genômicas de biobancos, apresentamos os resultados iniciais do primeiro Biobanco Latinoamericano em Acidente Vascular Cerebral (AVC). Métodos: Foram coletadas amostras de sangue de pacientes recrutados pelo Registro de AVC de Joinville e posteriormente de quatro cidades brasileiras. Foram registrados dados socioeconômicos demográficos, fatores de risco cardiovasculares, Causative Classification System (CCS), Trial of Org 10172 in Acute Stroke Treatment, National Institutes of Health, estado funcional (Rankin modificado) e imagens cerebrais. Adicionalmente, foram recrutados controles das regiões geográficas correspondentes. Obteve-se DNA genômico de todos participantes. Resultados: Foram incluídos 2688 pacientes e 3282 controles. Entre os pacientes, 76% tiveram AVC isquêmico, 12% ataques isquêmicos transitórios, 9% AVC hemorrágico e 3% hemorragia subaracnóidea. Os casos indeterminados foram os mais frequentes e classificados de acordo com TOAST (40%) e CCS (47%). Um quarto dos pacientes tinham menos de 55 anos no primeiro evento. Conclusões: Estabelecemos o Joinville Stroke Biobank, e discutimos aqui seu potencial na compreensão dos fatores de risco do AVC.

Humans , Male , Female , Middle Aged , Aged , Genome, Human/genetics , Biological Specimen Banks/statistics & numerical data , Stroke/genetics , Socioeconomic Factors , Brazil , Case-Control Studies , Risk Factors , Stroke/blood
Rev. chil. cardiol ; 36(2): 89-96, 2017. ilus, tab
Article in Spanish | LILACS | ID: biblio-899572


Introducción: La miopatía y fibrosis auricular representan el sustrato protrombótico y proarrítmico en pacientes con fibrilación auricular (FA). Estudios recientes muestran relación entre el strain auricular izquierdo (SAI), eventos cardiovasculares y recurrencia en pacientes con FA. La asociación entre SAI y bio-marcadores cardíacos como predictores de accidente cerebrovascular silente (ACVs) en pacientes con FA de reciente comienzo (FArc) no ha sido estudiada. Objetivo: Determinar si la asociación entre SAI y biomarcadores cardíacos contribuye a la predicción de ACV en pacientes con FArc. Métodos: Se realizó un estudio prospectivo que permitió reclutar 57 pacientes con FArc (primer episodio de < de 8 semanas de evolución). Obtenido consentimiento informado (CI) se realizó recolección de datos clínicos y muestras de sangre para determinación de Pro-BNP, Dimero-D y GDF-15. Se realizó resonancia nuclear magnética cerebral (RNMc) y ecocardiograma transtorácico (ETT) durante los primeros 3 días de inclusión y en ritmo sinusal. Para la evaluación de SAI se consideró la curva de deflexión positiva durante la sístole ventricular (SAIs), derivada de speckle tracking, considerando el promedio de 5 ciclos. Se utilizó Mann Whitney U test y Spearman Rho para análisis estadístico. Resultados: La edad promedio fue 70±8,2 años y el 70% fueron hombres. El CHA2DS2-VASc score promedio fue 3,1±1 y el promedio de pro-BNP, Di-mero-D y GDF-15 fue 96,1±12,4 pg/ml, 990±140 ng/ ml y 12 ng/ml respectivamente. 15% de los pacientes (n=9) presentaban ACVs en la RNMc al momento del diagnóstico. Se observó, además, que los pacientes con ACV presentaban un SAIs más bajo que los pacientes sin eventos (5,5±1,1% y 14,6±7,3% respectivamente p=0.04). Adicionalmente, se encontró una correlación significativa entre SAIs y pro-BNP, Dimero-D y GDF-15. Conclusiones: En este trabajo se evidenció que el 15% de los pacientes con FArc presenta ACVs al momento del diagnóstico. El SAIs bajo se correlaciona de forma inversa con los biomarcadores de sobrecarga, trombogénesis, fibrosis auricular y presencia de ACV silente. Estos resultados pueden ser utilizados para una mejor estratificación del riesgo de ACV en pacientes con FA.

Introduction: Atrial myopathy and fibrosis constitute a pro-arrhythmic and pro-thromboembolic substrate in patients with atrial fibrillation (AF). Recent studies using left atrial strain (LAS) have shown that LAS contributes to predict AF recurrence in patients with paroxysmal AF. The association between LAS and cardiac biomarkers in predicting silent stroke (SS) in patients with new AF has not been studied. Aim: The association of LAS and cardiac biomarkers contribute to predict SS in patients with new AF. Methods: We have prospectively evaluated 57 consecutive patients with new AF (first episode with less than 8 weeks of evolution). Baseline clinical characteristics and blood samples for determinations of Pro-BNP, D-Dimer and GDF-15 were obtained. Brain magnetic resonance (BMRI) and 2D Echo were performed within 3 days. In sinus rhythm, the positive deflection during ventricular systole of the LAS curve derived from speckle tracking was considered (mean of 5 cycles) (LASS). Mann Whitney U test and Spearman Rho were used for statistical analysis. Results: Mean age was 70±8,2 years, 70% were men. The mean CHA2DS2-VASc score was 3,1±1. Mean pro-BNP, D-Dimer and GDF-15 were 96,1±12,4 pg/ml, 990±140 ng/ml and 12 ng/ml, respectively. Fifteen percent of patients (n=9) had evidence of previous SS in BMRI. Patients with SS had significantly less LASS than patients without events (5,5±1,1% and 14,6±7,3% respectively p=0,04). In addition, a significant correlation between LASs and pro-BNP, D-Dimer and GDF-15 was found. Conclusion: Evidence of SS was found in 15% of patients with new AF. This was associated with LASs impairment, which was inversely correlated with cardiac biomarkers of LV overload, thrombogenesis and LA fibrosis. These findings could be utilized for a better risk stratification of stroke in patients with new AF.

Humans , Male , Female , Middle Aged , Aged , Atrial Fibrillation/complications , Stroke/etiology , Peptide Fragments/blood , Prognosis , Atrial Fibrillation/diagnosis , Atrial Fibrillation/blood , Fibrin Fibrinogen Degradation Products/analysis , Magnetic Resonance Imaging , Echocardiography , Biomarkers/blood , Prospective Studies , Risk Assessment , Natriuretic Peptide, Brain/blood , Stroke/diagnosis , Stroke/blood , Growth Differentiation Factor 15/blood
Clinics ; 71(12): 725-732, Dec. 2016. tab, graf
Article in English | LILACS | ID: biblio-840021


OBJECTIVES: The number of deaths from vascular diseases is incredibly high worldwide, and reliable markers for major events are still needed. The current cross-sectional study investigated the association of Klotho haplotypes and Klotho serum levels with classic risk factors and a clinical history of vascular events. METHODS: Clinical, anthropometric, biochemical and nutritional assessments were conducted with 168 older adults, complemented by genotyping (rs9536314 and rs9527025) and the detection of serum Klotho (ELISA). RESULTS: Klotho levels and haplotypes did not associate with most classic risk factors for vascular events, including markers such as C-reactive protein and homocysteine. A positive association was only found between Klotho levels and the previous occurrence of a myocardial infarction by both correlational (p=0.006) and variance analyses (p<0.001), and these associations were independent of the context. CONCLUSION: Our results suggest that serum Klotho is higher in individuals with a clinical history of myocardial infarction but not with a history of coronary artery disease or stroke. None of the Klotho haplotypes were associated with the variables investigated herein.

Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Glucuronidase/genetics , Glucuronidase/blood , Myocardial Infarction/blood , Reference Values , Coronary Artery Disease/genetics , Coronary Artery Disease/blood , Haplotypes , Energy Intake , C-Reactive Protein/analysis , Enzyme-Linked Immunosorbent Assay , Biomarkers/blood , Nutrition Assessment , Sex Factors , Anthropometry , Cross-Sectional Studies , Risk Factors , Analysis of Variance , Age Factors , Statistics, Nonparametric , Stroke/genetics , Stroke/blood , Genotyping Techniques , Homocysteine/blood , Myocardial Infarction/genetics
An. bras. dermatol ; 90(2): 265-267, Mar-Apr/2015. graf
Article in English | LILACS | ID: lil-741067


A sixty-one year old white female was referred to the Dermatology Department to treat an ingrown nail in the inner corner of the left hallux. Examination of the entire nail unit showed the presence of xanthonychia in the outer corner besides thickening and increase in the transverse curvature of the nail plate. Dermoscopy and nuclear magnetic resonance of the free edge of the nail plate detected characteristic signs of onychomatricoma, a diagnosis that was later confirmed by anatomopathological exam.

Humans , Anticholesteremic Agents/therapeutic use , Cholesterol Ester Transfer Proteins/antagonists & inhibitors , Fibric Acids/therapeutic use , Lipoproteins, HDL/blood , Niacin/therapeutic use , Coronary Disease/blood , Coronary Disease/mortality , Coronary Disease/prevention & control , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Myocardial Infarction/blood , Myocardial Infarction/mortality , Myocardial Infarction/prevention & control , Oxazolidinones/therapeutic use , Quinolines/therapeutic use , Randomized Controlled Trials as Topic , Stroke/blood , Stroke/mortality , Stroke/prevention & control , Sulfhydryl Compounds/therapeutic use
Arq. bras. endocrinol. metab ; 58(8): 817-823, 11/2014. tab, graf
Article in English | LILACS | ID: lil-729787


Objective This meta-analysis aimed to investigate the association of leptin levels with pathogenetic risk of CHD and stroke. Materials and methods Studies were identified in the PubMed, Embase, and Springer link database without language restriction. Odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) were used as effect indexes. The association of leptin levels with pathogenetic risk of CHD and stroke, as well as the risk variation of CHD with each additional one unit of leptin level were examined via meta-analysis. The publication bias was assessed via Egger’s linear regression test. Results Eight nested case-control studies consisting of 1,980 patients and 11,567 controls were included for current meta-analysis. ORs (95% CIs) of association of leptin levels with CHD and stroke was 1.90 (1.06, 3.43), and 2.14 (1.48, 3.08), respectively. In addition, significant result was obtained regarding the risk variation of CHD with each additional one unit of leptin level (OR =1.04, 95% CI =1.00‐1.08, P=0.044). There was no significant publication bias as suggested by Egger test outcomes. Conclusion There was a significant association of leptin with pathogenetic risk of CHD and stroke, and raised leptin levels could significantly increase the pathogenetic risk of CHD. .

Objetivo O objetivo desta metanálise foi investigar a associação entre os níveis de leptina e o risco patogenético de doença arterial coronariana e acidente vascular cerebral. Materiais e métodos Foram identificados estudos nas bases de dados PubMed, Embase e Springer Link sem restrição quanto à língua. A razão de chances (OR) e os intervalos de confiança de 95% correspondentes (95% CI) foram usados como índices de efeitos. A associação entre os níveis de leptina e o risco patogenético de doença arterial coronariana e acidente vascular cerebral com cada unidade adicional na concentração de leptina foi analisada por meio de metanálise. O viés da publicação foi avaliado por meio do teste de regressão linear de Egger. Resultados Oito estudos com caso controle aninhado envolvendo 1.980 pacientes e 11.567 controles foram incluídos na metanálise. As ORs (95% CIs) da associação entre as concentrações de leptina e a doença arterial coronariana e o acidente vascular cerebral foram de 1,90 (1,06; 3,43) e 2,14 (1,48; 3,08), respectivamente. Além disso, foram obtidos resultados significativos com a variação de risco para a doença arterial coronariana a cada unidade adicional na concentração de leptina (OR =1,04; 95% CI =1,00‐1,08; P=0,044). Não houve viés de publicação significativo sugerido pelos desfechos no teste de Egger. Conclusão Há associação significativa entre a leptina e o risco patogenético de doença arterial coronariana e acidente vascular cerebral, e concentrações aumentadas de leptina podem elevar significativamente o risco patogenético de doença arterial coronariana. .

Humans , Coronary Artery Disease/blood , Leptin/blood , Stroke/blood , Biomarkers/blood , Case-Control Studies , Coronary Artery Disease/genetics , Genetic Predisposition to Disease , Leptin/genetics , Odds Ratio , Risk , Stroke/genetics
Arq. neuropsiquiatr ; 72(10): 757-761, 10/2014. tab, graf
Article in English | LILACS | ID: lil-725338


Objective The objective of this study was to evaluate the relationship between unilateral spatial neglect (USN) and haemoglobin (Hb) level in acute phase of stroke. Method Cross-sectional study was performed after right hemisphere ischemic stroke. Independent variable: Hb level (mg/dL); Outcome: USN; Potential confounding factors: Age, National Institutes of Health Stroke Scale (NIHSS), and glycaemia (mg/dL); Characterization variables were obtained from electronic medical records, Hb, mean corpuscular volume (MCV) and glycaemia by laboratory exams, and USN by cancellation and bisection tasks. The relationship between Hb and USN was assessed by Spearman correlation and linear regression model. Results 40 individuals were evaluated; it was observed that the higher the Hb level, the better the USN test performance, with the two being negatively correlated. There was no significant correlation between VCM level and USN performance. Conclusion Low hemoglobin levels may indicate a worse performance in USN cancellation and bissection tests in acute phase of stroke. .

Objetivo O objetivo do estudo foi avaliar a relação entre a negligência espacial unilateral (NEU) e hemoglobina (Hb) na fase aguda do acidente vascular cerebral (AVC). Método Foi realizado estudo transversal em pacientes com AVC de hemisfério direito dentro das primeiras 48 horas do ictus. Variáveis independentes: nível de Hb (mg/dL); Desfecho: NEU; Fatores potenciais de confundimento: Idade, National Institutes of Health Stroke Scale (NIHSS) e glicemia (mg/dL); A caracterização das variáveis foram obtidas por meio de prontuários eletrônicos, Hb e glicemia por exames laboratoriais, e NEU por meio do Line Cancellation (LCT), Star Cancelation (SCT), e Line Bisection Tasks (LBT). Resultados 40 indivíduos foram avaliados e foi observado que quanto maior os níveis de Hb, melhor o desempenho nos testes de NEU, demonstrando correlação negativa entre eles. Conclusão Níveis baixos de hemoglobina podem indicar pior desempenho nos testes de NEU na fase aguda do AVC. .

Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Functional Laterality/physiology , Hemoglobin A/analysis , Perceptual Disorders/blood , Stroke/blood , Biomarkers/blood , Cross-Sectional Studies , Neuropsychological Tests , Perceptual Disorders/etiology , Severity of Illness Index , Stroke/complications , Stroke/physiopathology
Arq. neuropsiquiatr ; 71(11): 846-851, 1jan. 2013. tab, graf
Article in English | LILACS | ID: lil-691308


Atherosclerosis is an inflammatory disease, and ischemic stroke is one of its most common and devastating manifestations. Proinflammatory cytokines play a key role in the progression of the irreversible ischemic lesions. The presence of anti-inflammatory mediators may prevent secondary ischemic injury. Objectives 1) To assess the relationship between stroke severity and the serum levels of IL-1β, IL-2, and IL-10; and 2) To analyze the neurological outcome after 72 h of ischemic stroke onset and expression of interleukins. Method We measured the serum levels of IL-1β, IL-2, and IL-10 in 26 patients with acute stroke. Neurological impairment was scored using the National Institute of Health Stroke Scale within the first 72 h after stroke onset. Thirty healthy subjects were analyzed as controls. Results Patients with IL-10 <925.0 pg/mL presented with neurological deterioration within the first 72 h. Conclusion IL-10 may protect against ischemic injury during the acute phase of stroke. .

Aterosclerose é considerada um doença inflamatória e o acidente vascular cerebral (AVC) isquêmico uma de suas principais manifestações. Citocinas pró-inflamatórias exercem importante função na progressão para uma lesão isquêmica irreversível. A presença de mediadores anti-inflamatórios age prevenindo a lesão isquêmica secundária. Objetivos 1) Avaliar a relação entre gravidade do AVC e níveis de IL-1β, IL-2 e IL-10; 2) Avaliar a relação entre prognóstico neurológico nas primeiras 72 horas do AVC e o nível destas citocinas. Método Mensuramos os níveis de IL-1β, IL-2 e IL-10 de 26 pacientes com AVC isquêmico. O comprometimento neurológico foi avaliado através da escala do National Institute of Health nas primeiras 72 horas do AVC. Trinta indivíduos saudáveis foram usados como controles. Resultados Pacientes com IL-10 <925,0 pg/mL apresentaram deterioração neurológica nas primeiras 72 horas após o início do AVC. Conclusão IL-10 pode apresentar um efeito protetor contra a progresso da lesão isquêmica durante a fase aguda do AVC. .

Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Brain Ischemia/prevention & control , Interleukin-1beta/blood , /blood , /blood , Intracranial Arteriosclerosis/blood , Stroke/blood , Case-Control Studies , Disease Progression , Enzyme-Linked Immunosorbent Assay , Intracranial Arteriosclerosis/complications , Prognosis , Risk Factors , Severity of Illness Index , Statistics, Nonparametric , Stroke/etiology , Time Factors
Pakistan Journal of Neurological Sciences. 2013; 8 (4): 12-14
in English | IMEMR | ID: emr-139780


This descriptive study was conducted at Mayo Hospital, Lahore. A total number of 37 continuous patients with ischemic stroke were registered in one month. Imaging of the brain was done in each case. Both male and female patient of all age groups were included. Among these, 27 were males and 10 were females with the age range from 20 to 90 years. Nineteen patients [51.35%] had raised plasma homocysteine levels more than 15umol/l. Among patients with raised homcysteine levels, 14 [73.6%] were males and 5 [26.3%] were females. Eighteen [48.64%] patient fell in to group between 41-60 years of age. Eleven patients were younger than 40 and 8 were more than 60 years of age at the time of presentation. Out of 19 patients with raised plasma homocysteine levels 5 [26.3%] were also smokers and others were either non smokers or had stopped smoking more than 5 years back from the time of presentation. Four out of 19 [21.04%] patients had no other known cause of their stroke except raised plasma homocysteine. Theses patients were all males and were 23, 42, 60 and 68 years old. From our study we conclude that in our population, plasma homocysteine levels are raised commonly in patients of ischemic strokes, and it has already been established, as risk factor for all vascular events. We recommend routine measurements of Homocysteine levels in all Ischemic stroke patients and administration of Folic acid and Vitamin B12 as secondary preventive therapy

Humans , Male , Female , Stroke/blood , Stroke/complications , Homocysteine/blood , Epidemiology , Brain/diagnostic imaging , Hyperhomocysteinemia/prevention & control
Säo Paulo med. j ; 131(6): 384-388, 2013. tab
Article in English | LILACS | ID: lil-697427


CONTEXT AND OBJECTIVE: Arterial thrombosis may occur consequent to hereditary thrombophilia and increased lipoprotein(a) [Lp(a)] and fibrinogen. Our aim was to study the prevalence of common thrombophilia markers in 85 consecutive cases of arterial thrombosis. DESIGN AND SETTING: A retrospective study was conducted from 85 consecutive young patients treated as outpatients or admitted due to stroke or myocardial infarction at a tertiary care hospital. METHODS: Eighty-five Indian patients (age < 45 years) presenting ischemic stroke (n = 48) or myocardial infarction (n = 37) and 50 controls were studied for seven thrombophilia markers including antithrombin (AT), factor V, protein C, protein S, activated protein C resistance (APC-R), fibrinogen and Lp(a). Functional assays for protein C, protein S, factor V and APC-R were performed using clotting-based methods. Semi-quantitative estimation of fibrinogen was done using Clauss's method and Lp(a) using immunoturbidimetry. Statistical analysis was done using the Epi Info 6 software. RESULTS: Thirty-three samples (38.8%) tested positive for one or more thrombophilia markers. The three commonest abnormalities were elevated Lp(a) (20%), fibrinogen (17.6%) and low APC-R (14.2%). Low levels of protein C, protein S and AT were present in 4.7, 9.4 and 7% of the patients, respectively. Overall, the risk factor profile was: smoking (33%), positive family history (15.3%), hyperlipidemia (7%), hypertension, diabetes mellitus and obesity (2.3% each). CONCLUSIONS: An association was found between low levels of protein C, protein S and AT and arterial thrombosis, but only elevated fibrinogen levels, smoking, positive family history and hyperlipidemia showed statistical significance. .

CONTEXTO E OBJETIVO: Trombose arterial pode ocorrer em consequência de trombofilias hereditárias e de lipoproteína (a) [Lp (a)] e fibrinogênio aumentados. Nosso objetivo foi estudar a predominância de marcadores comuns da trombofilia em 85 casos consecutivos de trombose arterial. TIPO DE ESTUDO E LOCAL: Um estudo retrospectivo foi realizado sobre 85 pacientes jovens tratados consecutivamente no ambulatório ou admitidos por infarto do miocárdio ou acidente vascular cerebral (AVC) num hospital de cuidado terciário. MÉTODOS: Oitenta e cinco pacientes indianos (idade < 45 anos) que se apresentaram com AVC isquêmico (n = 48) ou infarto do miocárdio (n = 37) e 50 controles foram estudados para sete marcadores de trombofilia que incluíram antitrombina (AT), fator V, proteína C, proteína S, resistência ativada da proteína C (APC-R), fibrinogênio e Lp (a). Os ensaios funcionais da proteína C, proteína S, fator V e APC-R foram executados por métodos baseados em coagulação. A avaliação semiquantitativa do fibrinogênio foi feita pelo método de Clauss e a Lp(a) por imunoturbimetria. A análise estatística foi feita pelo software Epi Info 6. RESULTADOS: Trinta e três amostras (38.8%) foram positivas para um ou vários marcadores do trombofilia. As anomalias mais comuns foram Lp (a) (20%), fibrinogênio (17.6%) e APC-R (14.2%) elevados. Baixos níveis da proteína C, proteína S e AT foram detectados em 4.7%, 9.4% e 7% dos pacientes, respectivamente. Globalmente, os perfis dos fatores de risco foram: fumo (33%), antecedentes familiares positivos (15.3%), hiperlipidemia (7%), hipertensão, diabetes mellitus e obesidade (2.3% cada). CONCLUSÕES: Uma associação foi encontrada entre baixos níveis de proteína C, proteína S, AT e trombose arterial, ...

Adolescent , Adult , Child , Child, Preschool , Female , Humans , Male , Middle Aged , Young Adult , Myocardial Infarction/blood , Stroke/blood , Thrombophilia/blood , Thrombosis/blood , Age Factors , Activated Protein C Resistance/blood , Antithrombins/blood , Biomarkers/blood , Blood Proteins/analysis , Case-Control Studies , India , Lipoproteins/blood , Myocardial Infarction/complications , Reference Values , Retrospective Studies , Risk Factors , Smoking/blood , Stroke/complications , Tertiary Care Centers , Thrombophilia/etiology , Thrombosis/complications
Arq. neuropsiquiatr ; 70(2): 134-139, Feb. 2012. graf
Article in English | LILACS | ID: lil-612695


OBJECTIVE: To determine patterns of hyperglycemic (HG) control in acute stroke. METHODS: Anonymous survey through Internet questionnaire. Participants included Latin-American physicians specialized in neurocritical care. RESULTS: The response rate was 74 percent. HG definition varied widely. Fifty per cent considered it when values were >140 mg/dL (7.8 mmol/L). Intravenous (IV) regular insulin was the drug of choice for HG correction. One fifth of the respondents expressed adherence to a protocol. Intensive insulin therapy (IIT) was used by 23 percent. Glucose levels were measured in all participants at admission. Routine laboratory test was the preferred method for monitoring. Reactive strips were more frequently used when monitoring was intensive. Most practitioners (56.7 percent) monitored glucose more than two times daily throughout the Intensive Care Unit stay. CONCLUSIONS: There is considerable variability and heterogeneity in the management of elevated blood glucose during acute phase of stroke by the surveyed Latin-American physicians.

OBJETIVO: Determinar patrones de control de hiperglucemia (HG) en el ictus agudo. MÉTODOS: Encuesta anónima, mediante cuestionario vía Internet. Los participantes incluyan médicos latinoamericanos especializados en cuidados neurocríticos. RESULTADOS: Las encuestas fueron respondidas por el 74 por cento de los convocados. Las definiciones de hiperglucemia fueron variadas. El 50 por cento de los que respondieron consideran HG cuando glucemia >140 mg/dL (7.8 mmol/L). Insulina regular intravenosa fue la droga de elección para su control. Solo la quinta parte de los encuestados manifestaron adherencia a un protocolo. El 23 por cento emplea el régimen insulínico intensivo (TII). Glucemia fue obtenida a la admisión a la Unidad de Terapia Intensiva (UCI) por el total de los participantes. Test rutinario de laboratorio fue el método preferido para la monitorización. Tiras reactivas fueron utilizadas con mayor frecuencia cuando se aplicó monitoreo intensivo. El 56.7 por cento monitoriza glucemia más de dos veces al día durante la estadía en UCI. CONCLUSIONES: Existe una considerable variabilidad y heterogeneidad en el manejo de la hiperglucemia durante la fase aguda del ictus entre los médicos latinoamericanos encuestados.

Humans , Blood Glucose/analysis , Hyperglycemia/drug therapy , Stroke/blood , Acute Disease , Health Care Surveys , Hypoglycemic Agents/therapeutic use , Intensive Care Units , Insulin/therapeutic use , Latin America , Surveys and Questionnaires , Time Factors
Medical Journal of the Islamic Republic of Iran. 2012; 26 (2): 66-72
in English | IMEMR | ID: emr-144315


The role of uric acid as a risk factor for vascular disease and acute stroke is controversial and there is little information about it. In this study, we determined serum uric acid levels in patients with acute stroke and assessed its relationship with cerebrovascular risk factors. In this cross sectional study, we assessed patients with acute stroke who were admitted in Firoozgar Hospital from September 2010 to March 2011. Clinical records of patients and their serum uric acid level was investigated. Finally, collected data were analyzed using SPSS software Ver.16. Fifty five patients with acute stroke were evaluated who 25 of these patients [45.5%] were female and 30 of them [54.5%] were male. The mean age of patients was 67 +/- 14 years. Mean serum uric acid levels in the patients studied 5.94 +/- 1.70 mg/dl, and about half of the patients [47.3%] were hyperuricemic. There was a significant negative correlation between age of patients and their serum uric acid level [p=0.04, R =-0.27]. Uric acid level was significantly higher in men than women [p=0.03]. Hyperuricemia was associated with increased amounts of triglycerides and Low-density lipoprotein [LDL] cholesterol [p=0.03, p=0.02]. In patients with acute stroke, there was no significant association between serum uric acid level and diabetes mellitus, hypertension, history of ischemic heart disease, smoking, prescription rTPA, and type of stroke. Due to the high prevalence of hyperuricemia in patients with acute stroke, and its accompanying increase in triglyceride and LDL cholesterol levels, it can be considered as a risk factor for acute stroke

Humans , Male , Female , Aged, 80 and over , Adult , Middle Aged , Aged , Stroke/blood , Stroke/etiology , Uric Acid , Triglycerides/blood , Risk Factors , Cross-Sectional Studies
Neurosciences. 2009; 14 (3): 245-248
in English | IMEMR | ID: emr-101091


To investigate whether hypo-adiponectinemia is present in ischemic stroke patients. This comparative study was carried out in the Biochemistry Department, Ziauddin University, Karachi, Pakistan in 2008. In this study, plasma adiponectin concentration was measured by an enzyme-linked immunosorbent assay in subjects with and without ischemic cerebrovascular disease [CVD]. A total of 80 subjects were studied [40 patients with CVD, and 40 without CVD as controls]. The mean plasma level of adiponectin of the 40 patients with ischemic CVD was significantly lower than that of the 40 subjects without CVD [4.36 +/- 0.21 ug/mL versus 6.97 +/- 0.241 ug/mL; p=0.000]. Decreasing concentrations of adiponectin were negatively correlated with infarction size in ischemic CVD patients. These data show that there are significantly lower levels of plasma adiponectin in patients with ischemic CVD. Moreover, adiponectin is negatively correlated with infarction size in these patients suggesting the possible role of adiponectin in cerebrovascular disease

Humans , Male , Female , Stroke/blood , Brain Infarction , Enzyme-Linked Immunosorbent Assay , Cerebrovascular Disorders/blood
Journal of Arak University of Medical Sciences-Rahavard Danesh. 2008; 11 (3): 109-116
in English, Persian | IMEMR | ID: emr-87745


In the recent years, oxidative stress was attended as one of the causal factors of ischemic stroke. In terms of the role of genetic, geographic and ethnic factors in the prevalence of stroke, This study was designed to compare the oxidative stress indexes of stroke patients with normal healthy subjects in this geographic area. In this case-control study, 36 patients older than 50 years with ischemic stroke and 45 healthy subjects with same age and sex, were enrolled. Five milliliter blood were drawn from all subjects. Samples were centrifuged and plasma was separated. Total antioxidant capacity, lipid peroxidation and thiol levels were measured respettively by FRAP, TEA and HU methods. Then the result was analyzed using t-test. Results showed total antioxidant capacity and thiol plasma levels were lower in stroke patients in compare to healthy subjects, but only the thiol group had significant difference [P = 0/001]. Although lipid peroxidation showed a slight but non-significant difference in stroke patients in compare to control group. These findings suggest oxidative stress in patients with acute ischemic stroke may be conseaqence of an imbalance in oxidant/antioxidant homeostasis. Therefore it may be useful to recommend antioxidant medications or diet for these patients

Humans , Stroke/blood , Case-Control Studies , Lipid Peroxidation , Sulfhydryl Compounds/blood , Ischemia , Antioxidants
Arq. bras. endocrinol. metab ; 51(7): 1160-1165, out. 2007. tab, graf
Article in English | LILACS | ID: lil-470081


BACKGROUND: The apo B/apo A-I ratio represents the balance between atherogenic particles, rich in apo B, and the antiatherogenic ones, apo A-I rich. This study investigated the association between atherosclerotic diseases in different anatomical sites and apo B/apo A-I ratio. METHODS: Lipids, lipoproteins, and apolipoproteins A-I and B were assessed in 30 subjects with coronary artery disease (CAD), 26 with ischemic stroke (IS), 30 with peripheral arterial obstructive disease (PAOD), and 38 healthy subjects (controls). RESULTS: HDLc and Apo A-I were significantly lower in PAOD and CAD groups, respectively, than in other groups. Significantly higher levels of triglycerides were observed for CAD and PAOD groups than for controls. Apo B was significantly higher in IS group than in control and PAOD groups. The apo B/apo A-I ratio showed significantly higher in CAD and IS groups when compared to control and PAOD groups (p < 0.001). CONCLUSION: The apo B/apo A-I ratio was important for identifying an increased trend for coronary and cerebral atherosclerosis. In spite of the increased trend for apo B/apo A-I ratio in IS and CAD groups, the studied variables cannot be considered in an isolated way, given as those parameters were analyzed together by a binary logistic regression, no association has been demonstrated.

INTRODUÇÃO: O índice apo B/apo A-I representa o balanço entre partículas de colesterol potencialmente aterogênicas ricas em apo B e partículas anti-aterogênicas ricas em apo A-I. O objetivo deste estudo foi investigar a associação entre doenças ateroscleróticas em diferentes sítios anatômicos e o índice apo B/apo A-I. MÉTODOS: Lípides, lipoproteínas e apolipoproteínas A-I e B foram quantificados em 30 indivíduos apresentando doença arterial coronariana (DAC), 26 com acidente vascular cerebral (AVC), 34 apresentando doença arterial obstrutiva periférica (DAOP) e 38 indivíduos hígidos (grupo controle). RESULTADOS: HDLc e apo A-I apresentaram-se significativamente mais baixos nos grupos DAOP e DAC, respectivamente, quando comparados com os demais grupos. Níveis de triglicérides foram significativamente mais elevados nos grupos DAC e PAOD quando comparados com o grupo controle. Apo B foi significativamente mais elevada no grupo AVC quando comparado com os grupos controle e DAOP. O índice apo B/apo A-I se mostrou significativamente elevado nos grupos DAC e AVC quando comparados com os demais (p < 0,001). CONCLUSÃO: O índice apo B/apo A-I foi importante para identificar uma tendência aumentada para aterosclerose coronariana e cerebral. No entanto, os parâmetros avaliados não podem ser considerados de forma isolada, considerando que nenhuma associação foi demonstrada quando os dados foram analisados pelo modelo de regressão logística binária.

Adolescent , Adult , Aged , Child , Female , Humans , Male , Middle Aged , Apolipoprotein A-I/blood , Apolipoproteins B/blood , Arteriolosclerosis/blood , Coronary Artery Disease/blood , Peripheral Vascular Diseases/blood , Stroke/blood , Arterial Occlusive Diseases/blood , Arterial Occlusive Diseases/etiology , Arteriolosclerosis/etiology , Biomarkers/blood , Brain Ischemia/blood , Brain Ischemia/etiology , Cholesterol, HDL/blood , Coronary Artery Disease/etiology , Epidemiologic Methods , Pedigree , Peripheral Vascular Diseases/etiology , Risk Factors , Smoking , Triglycerides/blood
Article in English | IMSEAR | ID: sea-46658


Fibrinogen is an independent risk factor for coronary events in population-based studies and inpatients with coronary heart disease, but there is an uncertainty about its prediction for stroke, particularly in secondary prevention. In view of this uncertainty, study was conducted to establish the role of serum fibrinogen in ischemic stroke. Fifty six patients with acute ischemic stroke of less than 7 days duration were recruited for the study. Fourty two age and sex matched candidates served as control. Baseline characteristics and blood pressure were recorded at admission to hospital. Computer tomography head was done in all patients as per protocol. Sampling took place in the early morning (7-9 AM) using all necessary precaution and serum fibrinogen was measured by method of Clauss. Statiscal analysis was performed using student t test and fisher exact test. In present study, mean plasma fibrinogen in patients group was 326.45 mg/dl, which was significantly higher than control group (202.23 mg/dl) (p<0.001). Mean plasma fibrinogen level in lacunar infarct and non-lacunar infarct did not differ significantly (307.47 mg/dl Vs. 333.19 mg/dl). Smoking was found to be a significant predictor of fibrinogen with 36.7% predictability whereas other parameters (risk factors for ischemic stroke) had little or no predictable value regarding serum fibrinogen. After adjustment for other possible ischemic stroke risk factors; plasma fibrinogen levels was found to be still significantly high in patients as compared to controls (p<0.001). Mean plasma fibrinogen level between patients who survived and who expired does not differ significantly. Present study concluded that fibrinogen is a powerful predictor of ischemic stroke though it does not predict the type and prognosis of stroke.

Acute Disease , Brain Ischemia/blood , Case-Control Studies , Female , Fibrinogen/analysis , Humans , Male , Middle Aged , Risk Factors , Smoking/adverse effects , Stroke/blood
Article in English | IMSEAR | ID: sea-43552


BACKGROUND: Hyperhomocysteinemia was recently found to be a risk factor for stroke; however, the available data from Thailand is scarce. OBJECTIVE: To study plasma homocysteine levels in ischemic stroke and compare it with age-and sex-matched controls, and to identify the association of plasma homocysteine and subtype of stroke. MATERIAL AND METHOD: The authors studied plasma homocysteine levels of ischemic stroke patients with clinical signs and symptoms of stroke as confirmed by CT scan and compared them with control subjects who presented with other diseases and no clinical signs and symptoms of stroke between June 2000- May 2001 in Prasat Neurological institute. Fasting plasma homocysteine was measured by HPLC technique. Abnormal cut off point of plasma homocysteine was identified and associations of plasma homocysteine and stroke were studied by using logistic regression analyses. RESULTS: Two hundred and sixty-eight patients were recruited in the present study (132 controls and 136 ischemic stroke patients). The abnormal cut off point of plasma homocysteine was > 14 micromol/L. The authors found statically significant association of abnormal plasma homocysteine and stroke (p<0.001) with odds ratio of 4.277 (95%CI 2.551-7.171). After adjusting the confounding factor the authors found that high homocysteine was significantly associated with ischemic stroke (p<0.001) with odd ratio of 3.401 (95%CI 1.954-5.922). In the subgroup analyses of type of stroke and abnormal homocysteine, the authors demonstrated that abnormal homocysteine levels were more pronounced in the large vessel subtype than the small group. CONCLUSION: Abnormal homocysteine level is an independent risk factor of ischemic stroke and more correlated with large vessel subtype.

Adult , Aged , Aged, 80 and over , Brain Ischemia/blood , Case-Control Studies , Female , Homocysteine/blood , Humans , Hyperhomocysteinemia/blood , Male , Middle Aged , Risk Factors , Stroke/blood , Thailand/epidemiology